A few months ago, one of my patients (“Sue”) came in with the following complaints: “Help! I can’t sleep! I’m irritable, moody and short-tempered with my children and husband, and I’m having trouble concentrating at work. I know that menopause is a “natural” stage of life and not a disease, but gosh, I feel awful! Some of my friends take hormone replacements, but I’m worried about the health risks. What do you think I should do?”
Another woman (“Kay”) visited me the next week and told me how she was doing: “My periods are sporadic, and I have hot flashes several times a night. In fact, even when I’m not having a hot flash, my temperature never regulates properly, so I’m always too warm or too cold. This disrupts my sleep, so I end up feeling chronically tired and worn out. Plus, my muscles ache when I exercise. I want to feel as good as I did 3 years ago! Can you help me?”
These are the kinds of stories I hear from many of my patients who are entering menopause. During menopause a woman’s body dramatically decreases its production of estrogen, progesterone, and even testosterone. For many women these hormonal changes can cause a range of symptoms like those described by Sue and Kay.
Although there is no single solution that works for every woman, hormone replacement therapy can relieve many of the unpleasant symptoms that most women experience during menopause. When I explore the possibility of using hormone replacement with my patients, I make sure they understand both the benefits and the risks. Our discussions usually involve reviewing the latest medical research, but they always include evaluating each woman’s personal medical history, family history and symptomatology.
This is what I told Sue and Kay: Hormone replacement is not risk-free. Several years ago the Women’s Health Initiative (WHI) reported research results correlating the use of hormone replacement therapy with higher rates of breast cancer, strokes and heart disease. These results were very disconcerting, but it is important for everyone to understand what the WHI did and did not study.
The WHI focused on studying the effect of two hormones: “conjugated equine estrogen,” a hormone extracted from the urine of pregnant mares and marketed as “Premarin,” and “progestin,” a synthetic version of progesterone, which is marketed as “Provera.” Both of these hormones are similar to, but not the same as, the hormones that women naturally produce. And both of the studied hormones produce metabolites as they pass through the liver, which in turn, stimulate the production of proteins associated with heart disease, such as C-reactive protein, activating protein C, and clotting factors.
What the WHI did not investigate was the effect of treating menopausal women with “bioidentical” or “natural hormones”, the approach that I and many other physicians who specialize in women’s health take with patients. Briefly described, a bioidentical hormone is one that has been synthesized from a botanical source, which, by itself or in combination with other hormones, mimics the body’s natural state. Although Premarin may be “naturally occurring” in the sense that it is biologically produced by a horse, it does not mimic the effects of a woman’s own hormones as closely as bioidentical hormones made from plant extracts.
A recently released longitudinal study helped to further refine our understanding of the risks associated with hormone replacement therapy. Conducted by a group of French scientists and published in 2008 in the journal Breast Cancer Research and Treatment, the study evaluated more than 80,000 women who were taking hormone replacements. It concluded that the particular type of progesterone that a woman took with estrogen significantly affected her risk for breast cancer. Specifically, it showed that while Provera increased a woman’s risk for breast cancer, the bioidentical progesterone did not.
So, what should we do with all this information? Most importantly, how can we safely treat the symptoms of menopause that, at least for some women, can be so debilitating? To buffer the health impacts associated with lower estrogen levels, I often recommend the bioidentical hormone “Estradiol” because it most closely imitates the effect of estrogen on a woman’s body. A synthetic hormone made from soy and yam extracts, Estradiol can be used either by itself or in combination with another bioidentical hormone, Estriol (a weaker estrogen), via transdermal delivery, such as a patch, gel, or cream. Bioidenticals can be taken orally, but I prefer to prescribe transdermals because this delivery method bypasses the liver, thereby allowing the hormones to be absorbed directly through the skin, into the bloodstream, and on to the target cells (e.g., the brain, skin, vagina).
If a woman still has her uterus, it is important that her hormone replacement include both estrogen and progesterone. This combination protects the uterus from unopposed estrogen, which can cause the lining of the uterus to grow too much (“endometrial hyperplasia”), a condition that can lead to uterine cancer. Even if a woman’s uterus has been removed, however, I usually recommend taking progesterone for its own health benefits, such as reducing irritability and sleep disturbances and improving cognition. I often prescribe the oral form of micronized progesterone called “Prometrium.” (Avoid this product if you have a peanut allergy!) I also prescribe a compounded progesterone cream that women can use transdermally. Both of these progesterone products are derived from yams. When low libido presents a problem, testosterone also can be added into the bioidentical hormone cream or gel.
Once a woman begins taking bioidentical hormones, we closely monitor her symptoms and retest her hormone levels as needed, adjusting her treatment accordingly. I always remind my patients that choosing hormone replacement therapy is never a lifetime commitment; it is always a choice, and at any time you can decide to wean off and utilize other methods to improve your well being, such as herbal and nutritional remedies, acupuncture, meditation, and exercise. Furthermore, even when hormone therapy is an important part of feeling physically healthy and emotionally balanced, it is still just one piece. A woman’s activities, satisfaction with work, general health, relationships, nutrition, and exercise habits also will affect her overall sense of well-being.
If a woman chooses to go on hormone replacement, it is crucial that she continue to get her regular mammograms, pelvic exams, and pap smears. Annually, I meet with each patient to review her test results, and to discuss the latest medical literature on hormone replacement therapy. Then, in light of her particular health and life circumstances, we evaluate whether to continue treatment.
What did my patients Sue and Kay decide to do? Sue, who was feeling irritable and who was having trouble concentrating, decided to use a local compounding pharmacy that combined Estradiol, Estriol, and Progesterone into a cream that she can apply once a day before bed or after her shower. After three weeks of treatment, she reported that she was sleeping well, her mental concentration had improved, she felt calmer, and her family was grateful to have her back!
Kay, the patient who was having problems with temperature regulation, sleep, chronic fatigue and muscle pain, chose a combination treatment of an Estradiol patch and an oral dose of Prometrium. After following this regime for a month or two, she decided to switch from the patch to an Estradiol gel. Now she is feeling much more energetic, her temperature fluctuations and muscle pain have subsided, and she has been able to get back to her exercise routine.
So, if you or a woman you love is in menopause and is suffering with any of the symptoms described above, please know that you have options, including bioidentical hormone replacement therapy. For more information or to schedule an appointment so we can help you evaluate the best course of treatment for you, please call us at 703-532-4892.Print this page